VARIOUS TREATMENT

MODALITIES IN TMJ
DISORDERS
Guided by- Dr Ajaykumar Nayak Presented by- Dr. Supriya Shukla
Professor II MDS
Contents
• Introduction
• Definition
• Etiology
• Diagnosis/ Assessment
• Treatment Modalities
• Conclusion
• References
 Introduction
Functional disturbances of the masticatory system is complicated. Although numerous
treatments have been advocated, the complex nature of TMD requires a
multidisciplinary team.

Effective treatment selection begins with a thorough understanding of the disorder &
its etiology.

The management goals for the Prosthodontist as a member of a TMD team are patient
comfort, occlusal stability & the complex restoration of the teeth
 Definition

• Temporomandibular disorders (TMD) are a heterogeneous

group of musculoskeletal and neuromuscular conditions
involving the temporomandibular joint complex, and
surrounding musculature and osseous components
Anatomy
Normal movement of the condyle and disc
during mouth opening

Note that as the condyle moves out of the fossa the disc rotates posteriorly on the condyle. Rotational
movement predominately occurs in the lower joint space while translation predominately occurs in the
superior joint space.

When the mouth is closed (the closed joint position), the elastic traction on the disc is minimal to none. However, during
mandibular opening, when the condyle is pulled forward down the articular eminence, the superior retrodiscal lamina becomes
increasingly stretched, creating increased forces to retract the disc. In the full forward position, the posterior retractive force on
the disc created by the tension of the stretched superior retrodiscal lamina is at a maximum.
Clinical features
• The various clinical conditions are characterized by pain in the preauricular area,
TM joint, or muscles of mastication; limitation or deviation in mandibular range
of motion; and TM joint sounds (clicking, popping, and crepitus) during
mandibular function.

• Common patient complaints include headache, neck ache, face ache, and earache.

• Pulpitis, tooth mobility, tooth wear

• Other unexplained associated complaints include tinnitus, ear fullness, and perceived
hearing loss
 Etiological Factors
Predisposing Factors
Structural, metabolic, and/or
psychologic conditions that
adversely affect the masticatory
system sufficiently to increase the
risk of developing TMD.
It has been reported that an extreme
anterior open bite, overjet greater
than 6–7 mm discrepancy between
the retruded contact position and
five or more missing posterior teeth,
and unilateral maxillary posterior
lingual crossbite children may be
associated with TMD
Initiating Factors Perpetuating Factors
Those leads to the onset of Such as para function, hormonal
symptoms are primarily related to factors, or psychosocial factors,
trauma or repetitive adverse maybe associated with any
loading of the masticatory system predisposing or initiating factor and
can sustain the patient’s disorder,
Overt trauma producing injury to complicating management of it
the head, neck, or jaw can result
from an impact injury, possibly a
flexion–extension injury, and an
injury while eating, yawning, or
even from prolonged mouth
opening during long dental
appointments
Parafunction
Diagnosis/ Assessment
Screening for TMD is recommended as an essential part of all routine dental and/or orofacial pain
examinations. If significant findings are identified and recorded, a comprehensive history and examination
should be conducted.
Comprehensive History
Clinical Examination
• Cranial nerve examination
• Muscle examination
• Examination of TM Joint
Diagnostic Classification of TMD
1. Temporomandibular joint disorders 4. Inflammatory conditions
Congenital or developmental disorders - Capsulitis/synovitis
- Aplasia - Polyarthritides
– Hypoplasia 5. Noninflammatory (Osteoarthrosis)
– Hyperplasia - Osteoarthritis: primary
– Neoplasia - Osteoarthritis: secondary
2. Disk derangement disorders 6. Ankylosis
- Disk displacement with reduction – Fibrous
- Disk displacement without reduction – Bony
3. Joint dislocation 7. Fracture (Condylar process)
 Management
The majority of TMD patients achieve good relief of symptoms with a conservative model of
non-invasive management. Treatment Goals- reduction of pain, reduction of adverse
loading, improvement of function, and restoration of normal, daily activities.
• Patient Education and Self-care
• Cognitive Behavioural Intervention
• Pharmacotherapy
• Orthopaedic Appliance Therapy
• Occlusal Therapy
• Surgery
 Patient presents with symptoms
of temporomandibular disorder

Record history and physical examination

Recent trauma, dislocation, malocclusion, Yes Consider imaging (OPG ,

dental infection, or abscess? CT)
Refer to dentist or oral
maxillofacial surgeon
Abnormal cranial nerve findings?
No
Does the patient have any of the following findings?

Pain with mandibular Pain with biting or Masticatory muscle spasm or

movement chewing tenderness to palpation
Pain with mandibular Pain with biting or chewing Masticatory muscle spasm or tenderness to
movement palpation

Limited range Evaluate parafunctional Conservative therapy:

of motion, or habits (e.g., lip chewing, Patient education and self-care
painful jaw clicking nail biting, yawning, Behaviour modification
or popping?* teeth clenching) and wear Psychosocial interventions
patterns on dentition Trial of nonsteroidal anti-
inflammatory drugs, Muscle relaxant
for spasm
Conservative therapy Reevaluate in two to four weeks

Reevaluate in two to four weeks

Consider imaging
Continue conservative measures;
modify as appropriate
 Patient Education and Self-care
Instruction in a self-care routine should include the following:
• rest of the masticatory system through voluntary reduction of mandibular function,
• habit awareness and modification, and
• a home physiotherapeutic program.

A home physiotherapeutic programme of moist heat and/or ice to the affected areas,
massage of the affected muscles, and gentle range of motion exercises can reduce pain
and increase range of motion
 Cognitive Behavioural Intervention
Simple habits will often reduce when the patient is made aware of them, changing persistent habits may
require comprehensive stress management and counselling programs.

Behavioural strategies involving a combination of EMG biofeedback, relaxation techniques, and

self-directed lifestyle changes are more effective than any single behavioural treatment procedure.

In depth psychological evaluation and treatment by a mental health professional is recommended for
patients with long standing pain who have experienced multiple treatment failures.
Pharmacotherapy
The indicated classes of pharmacologic agents include analgesics, anti inflammatory agents,
corticosteroids, anxiolytics, muscle relaxants, and low-dose antidepressants.
Orthopaedic Appliance Therapy
Any removable artificial occlusal surface used for diagnosis or therapy
affecting the relationship of mandible to the maxilla (GPT-9).

Orthopedic appliances, also referred to as intraoral appliances, occlusal

splints, orthotics, night guards, or bruxism appliances, have a reported 70–90
% rate of clinical success.
GENERAL CONSIDERATIONS FOR OCCLUSAL APPLIANCE
THERAPY
• Initial therapy for TMD – reversible and non-invasive
• Diagnostic appliance
• Useful in reducing symptoms

The success or failure of occlusal appliance therapy depends on the selection ,

fabrication and adjustment of the appliance and on patient co-operation
 PROPER APPLIANCE SELECTION
• Identify the major contributing etiologic factor causing the disorder.
• No single appliance is useful with all TMD .
• In fact some TMDs does not respond to appliance therapy at all.

PATIENT CO-OPERATION
 effective only when the patient is wearing the appliance.
 Some require extensive use while others only part time use.
 THEORIES OF SPLINT ACTION
• Restored vertical dimension theory
• TMJ reposition theory
• Occlusal disengagement theory
• Cognitive awareness theory
• Maxillo-mandibular aliment theory.
 TYPES OF OCCLUSAL APPLIANCES- OKESON

• Stabilization appliance

• Anterior repositioning appliance

• Anterior bite plane

• Posterior bite plane

• Pivoting appliance

• Soft or resilient appliance

 DAWSON

Directive splints Pseudo

Muscle
or permissive
deprogrammer
splints, for
or permissive non-permissive
example, soft
splints splints splints.
 Stabilization Appliance
• Fabricated on the maxillary arch.

• When this appliance is in place the

condyles are in the most
musculoskeletally stable position at
the time that the teeth are contacting
evenly and simultaneously.

• It eliminates any orthopaedic

instability between the occlusal
position and the joint position.
 Indications
• Used to treat muscle pain disorders
• Patients reporting with TMD related to muscle hyperactivity s/a bruxisim
, local muscle soreness, centrally mediated myalgia.

• Retrodiscitis secondary to trauma

• Intracapsular disorder – continuous use

• If wearing the appliance increases the pain - discontinue immediately and report

• Patient returns in 2-7 days for evaluation

 ANTERIOR REPOSITIONING SPLINTS
• It encourages the mandible to assume a
more anterior position to the centric
occlusion
• The condyle head being held in more
inferior, anterior position
• This unloading of joint decreases the
inflammation in the joint and range of
mandibular movement increases
Anterior Repositioning appliance
 INDICATIONS
1. To treat disc derangement disorders. Patients with joint sounds (e.g., a single or
reciprocal click)
2. Intermittent or chronic locking of the joint (e.g., retrodiscitis)
3. Some inflammatory disorders are symptomatically treated as the slight anterior
position is more comfortable position for mandible.
Locating the correct anterior position
• Identify the most suitable position to
eliminate the symptoms
• The anterior stop is used to locate it.
• The patient is instructed to protrude slightly
and to open and close in this position.
• The joint is revaluated for symptoms and
the anterior position that spots the clicking,
is located and marked with red marking
paper.
 Final criteria for the anterior repositioning appliance
1. When in contact with the mandibular teeth, it
4.Inshould
the retruded
acuratelyrange
fit theofmaxillary
movement thewith
teeth lingual
total
retrusive
stabilityguidance ramp should contact and upon
and retention.
closure it should direct the mandible into the
In the established
2. established forward position all the
forward position
mandibular teeth should contact it with even
5.force
The appliance should be polished with smooth
surfaces and compatible with adjacent soft tissue
The forward position established by the
3. structures.
appliance should eliminate the joint
symptoms during opening and closing to
and from that position
 ANTERIOR DEPROGRAMMERS/ Anterior bite plane

•It is a hard acrylic appliance worn over

the maxillary teeth providing contact
only with the mandibular anterior teeth.
•It is primarily intended to disengage the
posterior teeth an eliminate their
influence on masticatory system
INDICATIONS
• Muscle disorders related to orthopedic instability
• an acute change in the occlusal condition
• Parafunctional activity- short duration

DISADVANTAGES
• there is a great likelihood that the unopposed mandibular posterior
teeth will supra-erupted and the result will be an anterior open-bite.
• Hence, therapy must be closely monitored and used only for short
periods.
 POSTERIOR BITE PLANE
• It is fabricated for the mandibular teeth.
• It consists of areas of hard acrylic located over the
posterior teeth and connected by a cast metal lingual
bar.
• The treatment goal is to achieve major alterations in
vertical dimension and repositioning of mandible .
 INDICATIONS
• Severe loss of vertical dimension or when there is a need
• to make major changes in the anterior repositioning of the mandible.

DISADVANTAGES
• Potential supra-erutpion of the unopposed teeth and/or intrusion of the
occluded teeth.
• Constant and long-term use should be discouraged.
 PIVOTING APPLIANCE
• The pivoting appliance is a hard acrylic device that
covers one arch and provides a single posterior
contact in each quadrant.
• This contact is usually established as far posteriorly
as possible.
• When superior force is applied under the chin, the
tendency is to push the anterior teeth close together
and pivot the condyles downward around the
posterior pivoting point.
• The pivoting appliance was originally developed with the idea that it would
lessen interarticular pressure and thus unload the articular surfaces of the joint.

• advocated for the treatment of symptoms related to osteoarthritis of the TMJs

and also for the treatment of an acute unilateral disc dislocation without
reduction
 SOFT OR RESILIENT APPLIANCE
• The soft appliance is a device fabricated from resilient material that is usually
adapted to the maxillary teeth.
• Treatment goals are to achieve even and simultaneous contact with the opposing
teeth.
INDICATIONS

1. Protective device for persons who are likely to receive trauma to

their dental arches
2. Protective athletic splints decrease the likelihood of damage to the oral
structures when trauma is received
3. Clenching and bruxism.
 Hydrostatic Appliance/ Aqualizer

A bilateral water-filled plastic chamber attached to an acrylic palatal appliance,

and the patient’s posterior teeth occlude with water filled chambers

The mode of mechanism of this appliance depends on the concept that the
mandible finds its ideal position automatically as the appliance was not directing
where the jaw should be.
COMMON TREATMENT CONSIDERATIONS OF
APPLIANCE THERAPY
1. Alteration of the occlusal condition
2. Alteration of the condylar position
3. Increase in the vertical dimension
4. Cognitive awareness
5. Placebo effect: 40% of the patients suffering from certain TMDs respond favourably
to such treatment
6. Increased peripheral input to the CNS: Any change at the peripheral input level
seems to have an inhibitory effect on this CNS activity. (Bruxism)
 CONCLUSION
• A proper examination and differential diagnosis is necessary to lead
to a decision regarding the appropriate role of splint therapy for the
particular condition.
References
• Management of TMD and occlusion 8th edition
• Kaur H, Datta K. Prosthodontic management of temporomandibular
disorders. The Journal of Indian Prosthodontic Society. 2013 Dec 1;13(4):40
• Gauer R, Semidey MJ. Diagnosis and treatment of temporomandibular
disorders. American family physician. 2015 Mar 15;91(6):378-86.0-5.
Thankyou !
Imaging
• The initial study should be plain radiography (transcranial and transmaxillary views) or panoramic
radiography. Acute fractures, dislocations, and severe degenerative articular disease are often visible in
these studies. Computed tomography is superior to plain radiography for evaluation of subtle bony
morphology. Magnetic resonance imaging is the optimal modality for comprehensive joint evaluation
in patients with signs and symptoms of TMD. Although there is a 78% to 95% correlation between
magnetic resonance imaging findings and joint morphology in symptomatic patients,
• Injections of local anesthetic at trigger points involving the muscles of mastication can be a diagnostic
adjunct to distinguish the source of jaw pain. This procedure should be performed only by physicians
and dentists with experience in anesthetizing the auriculotemporal nerve region. When performed
correctly, complication rates are low. Persistent pain after appropriate nerve blockade should alert the
clinician to reevaluate TMD symptoms and consider an alternative diagnosis